Provider Demographics
NPI:1679100523
Name:MYCOCUN, INC.
Entity Type:Organization
Organization Name:MYCOCUN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR & DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MORGAN
Authorized Official - Last Name:RAKAY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, BC-DMT
Authorized Official - Phone:267-908-4664
Mailing Address - Street 1:115 RED OAK DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN UNIVERSITY
Mailing Address - State:PA
Mailing Address - Zip Code:19352-8939
Mailing Address - Country:US
Mailing Address - Phone:672-908-4664
Mailing Address - Fax:
Practice Address - Street 1:115 RED OAK DR
Practice Address - Street 2:
Practice Address - City:LINCOLN UNIVERSITY
Practice Address - State:PA
Practice Address - Zip Code:19352-8939
Practice Address - Country:US
Practice Address - Phone:267-908-4664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty